Financing the RNFA Role

On May 11, 2010, Ontario's Minister of Health and Long Term Care (MOHLTC), the Honorable Deb Matthews, announced permanent 100% funding for 34 Surgical First Assistants, which is what the RNFA position is being called by the MOHLTC.

The 34 funded RNFA positions are in hospitals who participated in the pilot projects from 2007 - 2010. See below for more information.

There are additional RNFA positions funded through the cardiac budgets of Trillium Health Care Centre, Mississauga, Southlake Regional Health Centre, Newmarket and St. Mary's Hospital, Kitchener.

For hospitals who are interested in utilizing RNFAs, please contact directly:

Pinto, Marsha

Phone: 416-327-9690
Marsha Pinto
Senior Policy Advisor - NURSING SECRETARIAT, 12th Floor
56 Wellesley St W
Toronto ON M5S 2S3
E-mail: marsha.pinto@ontario.ca

Bournes, Debra

Phone: 416-212-4835
Debra Bournes
Provincial Cheif Nursing Officer - 12th Floor
56 Wellesley St W
Toronto ON M5S 2S3
E-mail: marsha.pinto@ontario.ca

Historical Perspective on Funded RNFA Positions

On May 3, 2006, the Ministry of Health and Long-Term Care (MOHLTC) news release stated "McGuinty Government Launches New Health Human Resources Strategy: HealthForceOntario Strategy Aims To Fill Shortage of Health Care Professionals. "

The HealthForceOntario strategy has three components, the first one being to:

Create four new roles in areas of need

  • Physician Assistants
  • Nurse Endoscopist
  • Surgical First Assist
  • Clinical Specialist Radiation Therapist

In 2007, the Ministry of Health and Long Term Care began funding 50% of RNFA positions in order to decrease wait times for orthopaedic surgery and evaluate the role for a two-year period. Round 1funded organizations were able to start funding positions as of January 2007 but needed to be linked to high volume orthopaedic centres.

In Round 2 funded organizations, the 50% funding formula was effective April 1, 2008 for a two-year period. The RNFA funding may now also be utilized to educate a Registered Nurse to become a RNFA in order to evaluate the position.

The funding is being monitored via the Nursing Secretariat's office of the MOHLTC. Only RNFAs are being funded through the HealthForceOntario strategy under the Surgical First Assist title.

Round 1 Funded Organizations

  • Hopital regional de Sudbury Regional Hospital
  • Hotel-Dieu Grace Hospital, Windsor
  • Joseph Brant Memorial Hospital, Burlington
  • Kingston General Hospital
  • Lakeridge Health Corporation, Oshawa
  • Quinte Healthcare Corporation, Belleville
  • Southlake Regional Health Centre, Newmarket
  • St. Michael's Hospital, Toronto
  • The Royal Victoria Hospital of Barrie Inc.
  • University Health Network, Toronto
  • Hamilton Health Sciences Corporation
  • Sault Area Hospital, Ste.Sault Marie
  • Sunnybrook Health Sciences Centre, Toronto
  • The Brantford General Hospital
  • The Scarborough Hospital

Round 2 Funded Organizations

  • Hanover & District Hospital
  • Headwaters Health Care Centre, Orangeville
  • Hopital General de Hawkesbury & District General Hospital
  • North Bay General Hospital
  • Orillia Soldiers' Memorial Hospital
  • Riverside Health Care Facilities Inc., Fort Francis
  • Rouge Valley Health System, Toronto
  • Sensenbrenner Hospital, Kapuskasing
  • St. Joseph's Health Services Association of Chatham, Incorporated
  • The Credit Valley Hospital, Mississauga
  • Timmins and District Hospital
  • University of Ottawa Heart Institute

In the past 12 years, numerous other ways of funding the RNFA position have occurred in Ontario.  The following is the text from the December 2004 issue of Canadian Operating Room Nursing Journal, Volume 22, Issue 4, entitled 'Show Me The $$$! Factors to Consider When Looking to Finance a RNFA Position' written by Grace Groetzsch, CRNFA.

Following the article, there are six (6) outlines of options for financing the RNFA role, which have found success in Ontario.


Factors to Consider When Looking to Finance a RNFA Position

Increasingly hospitals are looking to the Registered Nurse First Assistant (RNFA) position as a means to ensure readily available, qualified assistance for a patient's surgical intervention. Each year, in Canada, the number of RNFAs grows. As more individuals learn about the benefits of the position, through either direct experience or published reports, interest in the role increases. This, coupled with the reality of physician shortages, is bringing the RNFA role to the forefront in numerous hospitals across the country. Funding the position is one of the largest challenges that hospitals, and RNFAs, face in converting a recognized need into the reality of a paid RNFA position.

Why have hospitals with RNFA positions been successful? The reasons vary - not an answer that those struggling with the realities of implementing this position like to hear. Unfortunately it is not like a package of instant chicken soup - add hot water, stir, and voila! There are, however, common threads that should be considered by anyone investigating the RNFA position.

Firstly, the RNFA position is currently not a requirement in all hospitals. If surgical assistants (physicians or residents) are readily available the RNFA position has not been implemented. The RNFA has, however, had success in situations where physician/resident assistants are not available or where there is a shortage of available qualified assistants. The RNFA position is not intended as a replacement for all physician/resident assistants.

Secondly, hospital administration do not always appreciate that patient services and outcomes are being negatively impacted by a shortage of surgical assistants. It is not enough for operating room personnel to understand that additional surgical assistants are needed. Given that hospitals are generally the ones that finance the RNFA position it is of paramount importance that they understand the issues involved. Education is key to successfully implementing the RNFA position.

Beware of assumptions. Individuals working within the perioperative environment often assume that other healthcare workers understand what happens within the confines of the operating room environment. In the author's experience those outside of the OR environment, including other nurses and physicians, often have very little understanding of what is involved in successfully completing a patient's surgical experience.

Thus the challenges begin. Many healthcare providers do not understand that it takes a team of individuals to successfully complete an operation. The surgeon, in most cases, does not perform a procedure single-handedly. The team includes numerous personnel from nursing, anaesthesiology, and, in some specialty areas, registered respiratory therapy and perfusion. For the vast majority of operative procedures, the team includes a minimum of one surgical assistant. If a surgical assistant is unavailable procedures may be delayed or cancelled. Without a skilled surgical assistant, procedures can also take longer. It is well documented that a shorter operative procedure results in better patient outcomes.1,2 It is therefore imperative that everyone understands the significant role that a surgical assistant plays in a patient's perioperative experience.

In Canada most surgical programs and hospitals do not pay directly for their surgical assistants -- traditionally surgical assistants are physicians (often family doctors) who bill the provincial healthcare plan for their assisting services. Some provincial health departments, like British Columbia's, calculate precisely how much public money is paid out for surgical assistants.3 Most provinces, however, do not track this information.

Surgical residents also assist as part of their medical training, generally in teaching hospitals. Neither category of assistant, family physician or resident, is a hospital employee. Hospitals, therefore, do not have funds designated for surgical assistants. Being asked to fund a RNFA position is therefore something new - and something that there is no budget for.

It is relatively easy to do a side-by-side cost comparison between a full-time physician assistant and a RNFA. In unionized Ontario hospitals the bargaining unit for registered nurses (Ontario Nurses Association) has acknowledged the job classification of RNFA and RN/RNFA and a corresponding pay grid exists. For physician assistants access to the provincial fee schedule outlines remuneration for this position. A cost-effective analysis4 demonstrates that RNFAs provide cost effective care based on monetary reward alone. Additional benefits that a RNFA brings to the environment have been described in a previous article. (See CORNJ - June 2003 'Why A RN First Assistant? A Look at the Benefits….'). But for a hospital that has never had to budget for surgical assistants the $60,000 to $75,000, plus benefits, annual cost for each RNFA is significant. Ensuring that hospital administrators and finance personnel understand the importance of the assistant position, and the impact it has on delivery of care, is paramount to justifying this budget increase.

Thirdly, assumptions are often made about the quality of assistants available. Many individuals assume that the physician or resident assistant has the ability to complete surgery if something untoward should happen to the surgeon. In some rare instances a surgical assistant could complete the surgery. In most cases, however, this would not be true. The surgical assistant plays a complementary role to the surgeon - not an identical one. If something should happen to the surgeon intraoperatively then another surgeon would be called in.

Unbeknownst to most family physicians do not receive any special training to act as surgical assistants. Physicians may, or may not, have some experience depending on the electives they chose in medical school. Representatives of the Ontario Medical Association (OMA) and the Ontario College of Family Physicians acknowledge that most physician assistants do not have the ability to complete an operation should something happen to the operating surgeon.5 The role of a surgical assistant is, by definition, to assist. By virtue of their perioperative nursing background and formalized education RNFAs are well suited to act as surgical assistants.

Obtaining Funding:

There are ways for hospitals to fund RNFA positions. If the need is recognized, and patient care is being negatively impacted, hospitals, such as several in Ontario, are finding money within their budgets to fund RNFA positions. Both clinical (nursing and surgical) and administrative support are key to this method.

Some hospitals have chosen to assess the RNFA program via a pilot study. In this way funding is provided for a specific time period. Toward the conclusion of the study an evaluation determines the need for RNFA positions. Where there is a recognized need positions have often become permanent.

When a surgical program is implemented or expanded healthcare facilities submit funding proposals to the provincial government. At that time, the cost of RNFA positions can be factored into the cost of implementing/expanding the program. The case for including RNFAs must document a lack of surgical assistants or a quality initiative. In community hospitals this includes documentation that residents are not available and the difficulty of getting family physicians to assist, particularly during the day. The proposal should include the human resources aspect (i.e. number cases to be done, personnel required to do this, number of RNFAs to be utilized, outline of a job description) coupled with a financial impact statement. If the program/expansion is approved then the monies are available, and allotted, for RNFA positions. "Ask and ye shall receive!"

In an effort to retain experienced registered nurses some provincial nursing bodies are developing nursing initiatives that may be related to the RNFA position. For example, the Registered Nurses Association of Ontario is offering clinical fellowships that one hospital, and several RNFAs, are starting to take advantage of. This provides funding, for a short period of time, to evaluate the effectiveness of the RNFA position.

Thinking outside the box, coupled with a recognized need within the healthcare industry for surgical assistants, is the key to the financing of RNFA positions. By sharing their knowledge and resources employed RNFAs can help create additional RNFA positions. Information is key!

1. Wysocki, Annete (1989). Surgical Wound Healing: A Review For Perioperative Nurses. AORN 49 (2) 508.
2. Mangram, A., Horan, T et al (1999). Guideline for Prevention of Surgical Site Infection, 1999. Infection Control and Hospital Epidemiology 20 (4), 256.
3. British Columbia Ministry of Health Services, Medical Services Plan.
4. Groetzsch, Grace. Cost Effective Analysis - A RNFA working in cardiac surgery. Unpublished data, 1997/1998.
5. Ontario Medical Association. (January, 1998). Position Paper: Comments on Surgical First Assistant.

Ontario Nurses Association. www.ona.org
Registered Nurses Association of Ontario. www.rnao.org


Potential Funding Options

In all methods of funding, the RNFA is responsible for obtaining and maintaining professional liability insurance. In Ontario, this is available through RNAO's NurseInsure program brokered by Marsh Canada Inc. RNFAs must be a member of RNAO to access this program. For more information see www.rnao.org

The following options are in no particular order. The factors listed with each option is not fully comprehensive.

1. RNFA Self-Employment
· The RNFA needs to be a risk taker and amenable to being self-employed
· A contract for financial compensation is negotiated
· The contract specifies a specific period of time, which is renewal
· The hospital and/or surgeon pay for the RNFA. The RNFA is NOT a hospital employee.
· The RNFA is responsible for submitting taxes etc. to the government on a quarterly basis
· The RNFA is responsible for professional liability insurance and other benefits
· The RNFA invoices the surgeon/hospital for the agreed amount on a pre-determined timeframe e.g. once a month. Payment is due within 30 days.
· There are potential tax benefits for the RNFA
· For salaries over $30,000.00 GST must be charged by the RNFA
· Application for hospital privileges must be made to the hospital's Medical Advisory

2. New program expansion
· When the business plan for a new program (or current program expansion) is submitted to the Ministry of Health (MOH), RNFAs are included in the personnel section.
· Accompanying documentation outlines the requirement for RNFA position(s). This may include:
i. Community based hospital - no residents, medical students etc.
ii. Declining number of residents
iii. The requirement for an assistant for most surgical procedures
iv. Lack of available General Practitioners to assist in the operating room, especially during regular business hours
v. Statistics on the community's shortage of general practitioners

· The MOH may turn down the request initially. Articulate more clearly the requirement for RNFAs.
· This has method has been successful at St. Mary's Hospital, Kitchener and Southlake Regional Health Centre, Newmarket for their new cardiac programs.

3. Hospital Global Budget
· The hospital recognizes that without assistants surgical services to patients is detrimentally affected
· This is generally the result of extensive documentation of:
i. The advantages of having a pool of consistent assistants (See CORNJ - June 2003 'Why A RN First Assistant? A Look at the Benefits….'
ii. Time spent trying to book GP assistants and being unsuccessful
iii. Number of case delays and/or cancellations due to lack of an available assistant
iv. Beware of cost analysis RNFA versus OHIP billing. Remember that hospitals currently do not pay for assistants. A Cost analysis reflects the global cost to the healthcare system, which only indirectly effects the hospital.

· Funding the role may come from one of the following budgets within the hospital
i. Nursing department
ii. Operating Room budget
iii. Department of Surgery (may be service specific)

4. Physician Employed/Sponsored
· A surgeon or group of surgeons fund the RNFA role either directly or via a university research fund
· The RNFA remains a hospital employee
· The RNFA may work with only one surgeon. If so, the RNFA 'shadows' the surgeon in clinics, the OR and office settings
· This method has been successful with neurosurgeon Dr. John Wells and Suzin Ilton in Hamilton
· This method is also being utilized at the Royal Victoria Hospital in Barrie. Two OB/Gyn surgeons paid to have a RNFA assist on their operative days
· This method is also seen in private work e.g. Cosmetic plastic surgery clinics

5. Pilot Project
· The RNFA role is funded for a specific period of time in order to evaluate its effectiveness.
· Monies may come from a 3rd party e.g. ORNAC Research Grant, or from the hospital itself
· Upon completion of the pilot study timeframe, the role may or may not become permanent. At Rouge Valley Health Hospital, one permanent position was kept. Funding for additional RNFAs is currently being sought (Jan 2005).

6. Funding RNFA Education - RNAO's Advanced Clinical/Practice Fellowships for Nurses (ACPF)
· This method provides funding to educate a RNFA and is a variation of the pilot study
· In this case, the Registered Nurses' Association of Ontario provides the funds based on an identified 'need' or 'gap' in current services being provided at a healthcare organization in Ontario
· Nurse mentor required (Master's prepared RN; does not need to be in the OR) to develop and promote nursing knowledge & expertise
· Support must also come from the sponsoring organization
· The program is funded for 12 full-time or 20 weeks part-time
· $17,000 is available:
· $12,000 from RNAO
· $ 5,000 from the Sponsor organization

· Additional information available from RNAO's website: www.rnao.org

Points to Keep In Mind

· Dare to dream
· Plan ahead
· Know your environment
· Players
· Are programs expanding
· Situational factors
· Have a champion
· Work as a group/team
· Do not make assumptions
· Beware of assumptions
· Understand the importance of the assistance's role
· Educate, educate, educate, educate, educate…..
· Be assertive, not aggressive
· Know your facts/compile your resources
· Regulatory
· Liability
· Practice
· EXPECT opposition and plan for it
· Recognize when it's time to cut your losses and walk away
· Celebrate when successful and continue to support the RNFAs (see bullet re: opposition)